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Non Statin LDL Lowering and Vascular Events

Silverman et al report a meta-regression of randomized clinical trials of statin and non-statin trials. The relationship between change and LDL and relative risk is explored. Non-statin therapies associated with LDL receptor up-regulation showed similar event reductions per change in LDL-C.

Abstract

IMPORTANCE

The comparative clinical benefit of nonstatin therapies that reduce low-density lipoprotein cholesterol (LDL-C) remains uncertain.

OBJECTIVE

To evaluate the association between lowering LDL-C and relative cardiovascular risk reduction across different statin and nonstatin therapies.

DATA SOURCES AND STUDY SELECTION

The MEDLINE and EMBASE databases were searched (1966-July 2016). The key inclusion criteria were that the study was a randomized clinical trial and the reported clinical outcomes included myocardial infarction (MI). Studies were excluded if the duration was less than 6 months or had fewer than 50 clinical events. Studies of 9 different types of LDL-C reduction approaches were included.

DATA EXTRACTION AND SYNTHESIS

Two authors independently extracted and entered data into standardized data sheets and data were analyzed using meta-regression.

MAIN OUTCOMES AND MEASURES

The relative risk (RR) of major vascular events (a composite of cardiovascular death, acute MI or other acute coronary syndrome, coronary revascularization, or stroke) associated with the absolute reduction in LDL-C level; 5-year rate
of major coronary events (coronary death or MI) associated with achieved LDL-C level.

RESULTS

A total of 312 175 participants (mean age, 62 years; 24%women; mean baseline LDL-C level of 3.16 mmol/L [122.3mg/dL]) from 49 trials with 39 645 major vascular events were included. The RR for major vascular events per 1-mmol/L (38.7-mg/dL) reduction in LDL-C level was 0.77 (95%CI, 0.71-0.84; P < .001) for statins and 0.75 (95%CI, 0.66-0.86; P = .002) for
established nonstatin interventions thatwork primarily via upregulation of LDL receptor expression (ie, diet, bile acid sequestrants, ileal bypass, and ezetimibe) (between-group difference, P = .72). For these 5 therapies combined, the RRwas 0.77 (95%CI, 0.75-0.79, P < .001) for major vascular events per 1-mmol/L reduction in LDL-C level. For other interventions, the observed RRs vs the expected RRs based on the degree of LDL-C reduction in the trials were 0.94 (95%CI, 0.89-0.99) vs 0.91 (95%CI, 0.90-0.92) for niacin (P = .24); 0.88 (95%CI, 0.83-0.92) vs 0.94 (95%CI, 0.93-0.94) for fibrates (P = .02), whichwas lower than expected (ie, greater risk reduction); 1.01 (95%CI, 0.94-1.09) vs 0.90 (95%CI, 0.89-0.91) for cholesteryl ester transfer protein inhibitors (P = .002), whichwas higher than expected (ie, less
risk reduction); and 0.49 (95%CI, 0.34-0.71) vs 0.61 (95%CI, 0.58-0.65) for proprotein convertase subtilisin/kexin type 9 inhibitors (P = .25). The achieved absolute LDL-C level was significantly associated with the absolute rate of major coronary events (11 301 events, including coronary death or MI) for primary prevention trials (1.5%lower event rate [95%CI, 0.5%-2.6%] per each 1-mmol/L lower LDL-C level; P = .008) and secondary prevention trials (4.6%lower
event rate [95%CI, 2.9%-6.4%] per each 1-mmol/L lower LDL-C level; P < .001).

CONCLUSIONS AND RELEVANCE

In this meta-regression analysis, the use of statin and
nonstatin therapies that act via upregulation of LDL receptor expression to reduce LDL-C were associated with similar RRs of major vascular events per change in LDL-C. Lower achieved LDL-C levels were associated with lower rates of major coronary events.

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